Holiday Office Closure:

Our offices will be closed on December 24th, December 25th, and January 1st in observance of the holidays.

Financial Responsibility Form

Patient First Name(Required)

Patient Last Name(Required)

DOB(Required)

These are a list of terms that describe your (the patient’s) portion of the medical bills.

Co-payment: A cost sharing arrangement in which the patient pays a specific amount for a service. Co-pay amounts vary depending on a particular plan and are usually for specific services such as office visits, emergency room visits or prescription drug.

Deductible: The amount the patient must pay annually before the insurance company will pay any expenses.

Out-of-pocket (coinsurance): The amount not reimbursed by the insurance company that is the patient’s responsibility, such as deductibles, co-insurance, or co-pays. Coinsurance works after your deductible is paid.

IMPORTANT TO KNOW...

Our office bills your insurance company as a courtesy. Regardless of what type of insurance plan you may have, your medical bill is ultimately your responsibility.

Our billing office can answer any questions you have regarding your billing statement and set up a financial arrangement when necessary.

YOU WILL RECEIVE SEPARATE BILLING FOR LABS IF YOU ARE SELF-PAY OR DEPENDING ON YOUR INSURANCE PLAN.

Things to remember:

Notify our office immediately with any changes to your insurance, address, and phone numbers.
Bring a copy of your current insurance card to office visits.
Be prepared to pay any co-pays, co-insurance or deductibles at the time service is rendered.
Your insurance plan may require that you use certain hospitals or outpatient facilities.

Please feel free to email us at scheduling@bridgepointclinic.com for more questions or concerns.

Relationship to patient(Required)

Today's Date(Required)

Email(Required)

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